Severe anaphylaxis after pelvic examination: a case report o
Allergy, Asthma & Clinical Immunology 2019 15:19 reports a case of severe anaphylaxis after a pelvic examination performed on a 54-year-old Thai woman. She had had a spinal cord tumor surgically removed 4 years prior to the episode of anaphylaxis. She consequently had spastic paraplegia and became bed-bound. She developed one chronic pressure sore at the labia majora, for which she underwent multiple debridements. NRL gloves and CHX were regularly used in the debridements. Three days prior to the episode of anaphylaxis, she complained of vaginal spotting. A pelvic examination was done to diagnose the pelvic pathology. The gynecologist used CHX for the vaginal preparation and wore NRL gloves with lubricating gel during the examination. No other medications were administered during peri-procedural period. Approximately 5 min after the examination, she began to complain of “feeling unwell” with mild vaginal pruritus.

She rapidly developed generalized hives and flares, swollen eyelids, and hypotensive syncope, all within 30 min. She was diagnosed with severe anaphylaxis. Intravenous fluid and intramuscular epinephrine were promptly administered. All symptoms improved without a biphasic reaction.

Additional history revealed that she had a history of minimal pruritus after direct skin contact with latex gloves during a bed bath procedure 1 month before. Although NRL gloves and CHX as a disinfectant were regularly used in her debridements, she had never had a history of a systemic allergic reaction after a debridement. Since the age of 50, she had had a history of fruit allergy (including bananas, longans, and jackfruit) associated with symptoms of pruritus of the lips, urticarial rashes, and angioedema. She had never eaten avocado, kiwi, or other latex-related fruits.

Investigations into the cause of the anaphylaxis were done thoroughly 6 weeks after the episode.

Given the patient’s history of severe index reaction, we initially performed skin prick testing with CHX at a concentration of 0.002 mg/mL, which proved to be positive. A basophil activation test showed an increased expression of CD203c in basophils when stimulated with CHX. Its stimulation indices were 4.03 and 4.52 when whole blood was stimulated with CHX at the concentrations of 0.1 and 0.3 mcg/mL, respectively. Specific IgE to latex, using ImmunoCAP, was positive at 45.90 kAU/L. We analyzed specific IgE to latex component, which showed positive results for Hev b 1, 5, 6.02, and 11 (Phadia AB, Uppsala, Sweden). Prick-to-prick testing with latex-related fruits was positive for avocado, banana, jackfruit, kiwi, and longan. A glove-use test revealed contact erythema with concurrent pruritus on the fingertip at 20 min.

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